Provider Demographics
NPI:1528290327
Name:BAUTISTA, MIGUEL ANGEL (LAC)
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ANGEL
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4318 W. FOREST HOME AVE.
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53219
Mailing Address - Country:US
Mailing Address - Phone:847-224-6159
Mailing Address - Fax:847-829-3991
Practice Address - Street 1:4318 W. FORESTHOWE AVE.
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53219
Practice Address - Country:US
Practice Address - Phone:847-224-6159
Practice Address - Fax:847-829-3991
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI637-055171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist